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    Provided for non-commercial researchand education use. Not for reproduction, distribution or commercial use. Read Articles in PressOnline WWW'.ljpmoonline.nd AMERJCAN JOURNALOF Theo e  _ Cllmote Chadp   the_ of the Public Guelit Edi((Jor:;l: ILuwaf'd. FnamlUn. Anthony J. At Michael. il.ndJif'N m), J. H~ IfflitMdiWC,jffli ... aimllle Q an~. Air QUlIlhy. lWd '0' ClimllU ChlUl~ and th~ Health or tbt HumllDHealtb Public I'LKtllllli' 11 J'mmLm. AJ Mdtw:h:u-l, IJ IkJol 'HiS CUm.'': Tbt- Impnrun<T' of '0' CJJ.m.le au..n~ and Public:He.altlu Plan' Tbinkmg. Cwunwdt. il.lin~ ãã o\cting II ~~~, I \1 lo1l1.-.\ \r p;. ~mU Jll lll-rllnlbn.AI..\tdlw:h ãã d l:Me IifIM'k'1 i 'Wfii1'blj d 'MMiJii' 47. PubUc Perception ur Climllle Chao,g~   Clhn.lI~ Clunge and Helilth: Voluntary .Mlti.gation and BIlniif' , to BehaviorClw:i:Je St.reup.eoing the E~ id~~ Buefur JC  \(-n, .. m: . tn.  t .. l. f. f W,h'on, Polk-y SO BorIIt:flIl..... 0J s..u}.. .LAGo.:U I~l AII,un.,., 48. CoOU.J)uDkation.andMIIrlr ,ijng AI  .  11Unk Luc:dl)'. Act Globally: How Oimll .... Chilo,v-lnil:fT ntioD ~l CurbingGlobal A Public JIr'alth  ~ r Can hbpl Oh~ Looc:al Publl:c: fW M . ,h ... h,  : ~r.R l< IHf. 'tk8lo,.lOmbo'l: KI,wtn<al,t <\1..MKrtl'Kil . ...   Yt 'llr2008.: ABrt 'llklhruugh YtJIJ Ol Health Prot«doo rromQlmaU' @,6i1WWfbfflii.l. ChiDlt~~ SOl Communit  ~ Ad;llpL;i.liun 1.0 lhe   tOint,RlklluUllIi, Helthh lmpat'Ul of CllllUl~ o.ang~ DC:ampl..dJ-I .. ·1L.hlllll. OJ Ik~11\;I.1m KJ. t la.Jr Srmcna ... ClImAte OLRnl '. HellithScleDCti, and SO. BW1dlft1 Hwoan I«slUetu:e: 111~ Role Eduoetdon of PubUc H~llith Preplltednft15 and R.. . I.'' ITf'I,(C'', PI') S~ lfld, t R.. spmJSf:: Ali I.J1 '\daptlUion 10 Gljm;ll(> i j IMi1 iWMI@iIbij .. ¥ ; a. ......  PJ;rml ... CUmale CbtID~ and E:l:lr'elllll Heat 517 The Built Ln1runnlenl. C1.inUl~ E\'lmtJ and Ht' OppurlWlitit's G Lut~,. :11 \to:<~·dllll fQr Co-fkn,,6ts ... CUmalEl and V~torb(>ftle DIseases \ ~UUI1~1 Ilk :'olmrow-J'lllWm. Ji.l  ;~. TR KtltU.I, kJ t.. .. n, Lb lit) ,' S~I \'i dlKlll,ALlhlm.--nbo-1Jli ... Olmate  anp lltLd Wawrbome laoM :Mi. DJ5iI ase I&k In me G1 e8.t Lakes hgtoa of LbeLoS. . aIm.te Qlan~ lmpa.clS on Old j,\ Plm. ~I \' 'l lUl. t:j. t.·W'. Implic;ltjo~ rOf {ilob:d 11 .. a.ltb  l \hl..rll.lll\U' '\1 1~ 11 lJllf ll'} This   article   appeared   in   a   journal   published   by   Elsevier.   The   attached   copy   is   furnished   to   the   author   for   internal   non-commercial   research   and   education   use,   including   for   instruction   at   the   authors   institution   and   sharing   with   colleagues.   Other   uses,   including   reproduction   and   distribution,   or   selling   or   licensing   copies,   or   posting   to   personal,   institutional   or   third   party   websites   are   prohibited.   In   most   cases   authors   are   permitted   to   post   their   version   of   the   article   (e.g.   in   Word   or   Tex   form)   to   their   personal   website   or   institutional   repository.   Authors   requiring   further   information   regarding   Elsevier’s   archiving   and   manuscript   policies   are   encouraged   to   visit:    Author's personal copy The Built Environment, Climate Change, and Health Opportunities for Co-Benefits Margalit Younger, MPH, Heather R. Morrow-Almeida, MPH, Stephen M. Vindigni, MPH, Andrew L. Dannenberg, MD, MPH  Abstract:  The earth’s climate is changing, due largely to greenhouse gas emissions resulting fromhuman activity. These human-generated gases derive in part from aspects of the built environment such as transportation systems and infrastructure, building construction andoperation, and land-use planning. Transportation, the largest end-use consumer of energy,affects human health directly through air pollution and subsequent respiratory effects, as well as indirectly through physical activity behavior. Buildings contribute to climatechange, influence transportation, and affect health through the materials utilized,decisions about sites, electricity and water usage, and landscape surroundings. Land use,forestry, and agriculture also contribute to climate change and affect health by increasingatmospheric levels of carbon dioxide, shaping the infrastructures for both transportationand buildings, and affecting access to green spaces. Vulnerable populations are dispropor-tionately affected with regard to transportation, buildings, and land use, and are most at risk for experiencing the effects of climate change. Working across sectors to incorporatea health promotion approach in the design and development of built environment components may mitigate climate change, promote adaptation, and improve public health. (Am J Prev Med 2008;35(5):517–526) Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine. Introduction E behaviors can help reduce GHG emissions, climatechange, and adverse health consequences. vidence indicates that the global climate isThe built environment influences human choices,changing, resulting in elevated temperatures, which in turn affect health and the global climate.rising sea levels, heavier precipitation eventsDistinct from the natural environment, the built envi-(e.g., floods, storms, hurricanes, and cyclones), addi-ronment is comprised of manmade components of tional heatwaves, and more areas affected by drought. 1 people’s surroundings, from small-scale settings (e.g.,Possible health consequences include morbidity and offices, houses, hospitals, shopping malls, and schools)mortality related to heat, extreme weather events, vec- to large-scale settings (e.g., neighborhoods, communi-torborne and waterborne infections, mental stress, food ties, and cities), as well as roads, sidewalks, greenand water shortages, respiratory diseases, international spaces, and connecting transit systems. The develop-conflict, and air pollution. 2,3 Greenhouse gas (GHG) ment of the built environment involves many sectors,emissions, composed mainly of carbon dioxide, meth- including urban planning, architecture, engineering,ane, nitrous oxide, and fluorinated gases, 4 increased local and regional governments, transportation design,70% from 1970 to 2004, 5 contributing to these changes. environmental psychology, and land conservation.Carbon dioxide (CO 2 ) emissions, in particular, ac- Neighborhood design not only influences health by counted for 77% of total anthropogenic GHG emis- affecting physical activity, respiratory and cardiacsions in 2004. 5 Because these emissions are largely a health, injury risk, chronic disease risk, social connect- 6 result of human activity, 1 changes in policies and edness, and mental health, but many current commu-nity design practices also adversely contribute to globalclimate change. From the National Center for Environmental Health/Agency for  The UN Intergovernmental Panel on Climate Toxic Substances and Disease Registry, CDC (Younger, Morrow-  Change has noted the relationship between compo-  Almeida, Vindigni, Dannenberg); Office of Workforce and Career nents of the built environment and climate change, Development, Career Development Division, Public Health Preven-tion Service, CDC (Morrow-Almeida); and Emory University, School  reporting that global GHG emissions have grown of Medicine (Vindigni), Atlanta, Georgia  largely as a result of the following sectors: energy   Address correspondence and reprint requests to: Margalit  supply, transportation, industry, land use and forestry,  Younger, MPH, Office of Policy, Planning, and Evaluation, NCEH/  5  ATSDR, CDC, 4770 Buford Highway, MS F-61, Atlanta GA 30341.  agriculture, and buildings. Strategies that aim to re- E-mail: .  duce atmospheric CO 2  include decreased use of motor  Am J Prev Med 2008;35(5) 0749-3797/08/$–see front matter  517 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine doi:10.1016/j.amepre.2008.08.017  Author's personal copy  vehicles, increased energy efficiency in buildings, and thereby affecting injury rates among drivers, pedestri-reduced deforestation. 7 Based on these strategies, the ans, and bicyclists, as well as climate change.current study focuses on three built environment com- Climate change and air quality have an interactiveponents: transportation, buildings, and land use (in- relationship. Climate change affects air quality by alter-cluding forestry and agriculture). ing local weather patterns, such as temperature andThese aspects of the built environment may dispro- wind speed, which affect the distribution of air pollu-portionately affect vulnerable populations, such as chil- tion. Anthropogenic sources of air pollution (e.g.,dren, the elderly, people with disabilities, racial and motor vehicles) promote climate change through theirethnic minorities, and people of low SES, particularly  emission of CO 2 , volatile organic compounds (VOCs), when effects on health are not incorporated into built  and nitrous oxide. 14 The combination of VOCs, nitrousenvironment decision making. These populations are oxide, and sunlight form ozone and smog, which arealso among the groups most susceptible to health harmful to health. 15,16  Although no direct health ef-effects caused by climate change. 8 The health effects fects are attributed to increased ambient levels of experienced by vulnerable populations are highlightedCO  172 , high concentrations of indoor CO 2  are asso-in this article.ciated with drowsiness, headaches, poor concentra-Because the built environment constitutes an impor-tion, and increased heart rate; and extremely hightant contributor to climate change and health out-concentrations of CO 2  (  5000 parts per millioncomes, alternative practices offer opportunities both[ppm]) potentially lead to oxygen deprivation andfor improved health and reduced climate change. Thisserious health effects. 18 Other byproducts of fossilarticle presents the current evidence and potentialfuel combustion (e.g., ozone and fine particulateco-benefits of alternative practices, and illustrates built matter) contribute to air pollution and associatedenvironment strategies that minimize the effects of respiratory illnesses. 14,19,20 climate change and improve health (Table 1). Oppor-Exposure to air pollutants is linked to chronic ob-tunities for partnerships between health sectors andstructive pulmonary disease hospitalizations, 21 respira-non–health sectors sharing similar goals are also exam-tory and cardiovascular morbidity and mortality, 22 ined. Finally, next steps and areas for further researchacute asthma care events, 23 diabetes mellitus preva-are suggested.lence, 24 lung cancer risk, 25 birth defects, 26 lung impair-ment, fatigue, headaches, respiratory infections, and  Transportation  eye irritation. 20  Air pollution health effects are partic-ularly associated with SES and age. Asthmatic childrenTransportation, a key feature of the built environment,living in areas with low SES were found to be moreencompasses roads, highways, airports, railroads, publicaffected by air pollution than asthmatic children in high-transit, ports, and bicycle trails, as well as the interac-SES regions. 27 Emergency room visits for air pollution–tion of these systems with cities and communities.related asthma were highest among young children andTransportation accounted for 28% of total U.S. GHGthe elderly. 28 Thus, increased exposure to air pollut-emissions in 2006, of which 94% was from energy-ants, which climate change may intensify, can exacer-related CO 2  emissions. Furthermore, transportationbate respiratory illnesses for those most vulnerable, was the largest end-use sector producing energy-relatedsuch as children, 29 athletes, asthmatics, and peopleCO 2  emissions in 2006, nearly all of which was caused with  14 by petroleum combustion. 9  cardiac or pulmonary conditions.Three aspects of the trans-Transportation infrastructure affects physical activity portation sector contribute to GHG emissions: fuelas well. A study of five pedestrian and bicycling trails inefficiency of vehicles, carbon content of fuel, and vehicle miles traveled. 10  Nebraska found the average cost per user in 2002 wasOf these, vehicle miles traveledaffects GHG emissions directly through the built  $235, but resulted in medical cost savings of $622 perenvironment. person from engaging in physical activity. 30 Trails offerTransportation infrastructure and systems affect both multiple co-benefits, by improving physical activity lev-GHG emissions and public health. Transportation pat- els, providing alternative transportation routes, andterns are related to pedestrian and motor vehicle preserving green space. Walking, bicycling, and usingfatalities and nonfatal injuries. 11 Motor vehicle crashes mass transit (which often includes walking) for com-account for more than 40,000 deaths and almost 3 muting purposes can increase physical activity, 31,32 million injuries a year in the U.S. 12 In addition, injury  which in turn enhances psychological well-being andrates among pedestrians and bicyclists are higher in the reduces risks of mortality, cardiovascular disease,U.S. than in Germany or the Netherlands, although stroke, colon cancer, diabetes mellitus, and depres-Germany and the Netherlands have substantially  sion. 33 Less time in automobiles reduces exposure togreater rates of walking and bicycling. 13 By reducing busy traffic and “road rage” 34,35 and decreases thedistances between destinations and decreasing vehicle likelihood of obesity, 36  while simultaneously reducingmiles traveled, transportation designs can be altered, GHG emissions. 518  American Journal of Preventive Medicine, Volume 35, Number 5   Author's personal copy Table 1.  Relationships among the built environment, climate change, and health Built environment Link to greenhouse gascategory emissions and climate change Built environment strategies Impacts Health co-benefitsTransportation  ●  Fuel consumption  ●  Increase proportion of people  ●  Improved air quality from  ●  Reduced motor vehicleassociated with personal and and goods transported on reduced motor vehicle injuries and fatalities fromcommercial vehicle use rails rather than roads emissions reduced motor vehicle travel ●  Number of vehicle miles  ●  Promote telecommuting  ●  Increased physical activity   ●  Reduced levels of respiratory traveled per capita  ●  Decrease air travel from walking and illnesses (e.g., asthma) due to ●  Long distances between  ●  Decrease distances between bicycling improved air quality homes, jobs, schools, and destinations (denser and  ●  Enhanced social capital  ●  Reduced likelihood of other destinations mixed-use development) cardiovascular diseases, some ●  Long distances from farm  ●  Increase facilities and cancers, and osteoporosis, dueand factory to market opportunities for transit use, to increased physical activity  walking, and bicycling  ●  Improved mental health and ●  Promote safe routes to school decreased depression andprograms anxiety, due to enhanced ●  Promote use of food and social capitalgoods from local suppliers ●  Develop infrastructure foralternative fuel generationand distribution Buildings  ●  Energy use in producing  ●  Increase use of sustainable,  ●  Improved air quality from  ●  Reduced levels of respiratory and transporting local, and/or recycled reduced coal-generated illnesses (e.g., asthma) due toconstruction materials construction materials and electricity improved air quality (“embedded energy”) reuse of older buildings  ●  Increased physical activity   ●  Reduced likelihood of  ●  Energy use in construction  ●  Increase heating and cooling from stair use cardiovascular diseases, somepractices efficiency through site  ●  Decreased heat island cancers, and osteoporosis, due ●  Energy use in heating and orientation, insulated effects to increased physical activity cooling windows, green roofs, and  ●  Improved mental health and ●  Energy use in building natural ventilation productivity from use of day-operations, such as lighting  ●  Decrease electricity use by lightingand elevators occupants by providing  ●  Reduced susceptibility to heat- ●  Building site choices that convenient stairs, compact related illnesses due topromote automobile florescent bulbs, day-lighting, decrease in heat island effectsdependency and sprawl and motion sensor light switches ●  Adopt LEED guidelines forenergy-efficient buildings ●  Use less square footage whendesigning and buildinghouses ●  Reduce drive-through servicesthat typically involve idlingautomobiles Land use, forestry,  ●  Deforestation associated  ●  Develop mixed-use  ●  Increased physical activity   ●  Reduced likelihood of  and agriculture  with logging, agriculture, communities following smart from walking and cardiovascular diseases, someand sprawling development growth and LEED-ND bicycling in mixed-use cancers, and osteoporosis, due ●  Separation of land uses, principles communities to increased physical activity  which increases travel  ●  Preserve and expand parks,  ●  Improved social capital  ●  Improved mental health and ●  Buildings constructed in trails, and green space from use of parks and decreased depression and vulnerable areas, such as  ●  Encourage community trails and contact with anxiety, due to improvedcoastal regions and flood gardens and farmers’ markets nature social capitalplains  ●  Reduce construction in  ●  Improved nutrition and  ●  Reduced fatal and nonfatalcoastal locations, flood plains, social capital from locally injuries from severe weatherand other vulnerable areas grown food events ●  Provide incentives to protect,  ●  Increased multi-usemanage, and sustain forests forests for recreation and ●  Coordinate regional planning commercial use ●  Support sustainable loggingand agriculture ●  Reduce demand for meat consumptionLEED, U.S. Green Building Council’s Leadership in Energy and Environmental Design rating systems; LEED-ND, for neighborhood development  Communities highly dependent on automobiles pose recreational facilities encourage people with limitedmobility barriers for children, the elderly, those without mobility or special needs to stay physically active, inde- vehicles, and people with mobility impairments. Acces- pendent, and involved in community activities. 37,38 sible, walkable, and safe neighborhoods with mixed- Among the elderly, exercise is associated with lowerland use, good connectivity, public transit options, and rates of functional decline 39 and dementia, 40 and may  November 2008 Am J Prev Med 2008;35(5)  519
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